CPT code 21085 is for preparing a face or oral prosthesis, detailing the specific medical service provided.
CPT code 21085 is used for the preparation of a face or oral prosthesis. This involves creating a custom-made device to replace or support facial or oral structures, often necessary after surgery, trauma, or for congenital conditions.
When billing for CPT code 21085 (Prepare face/oral prosthesis), it is essential to consider the appropriate use of modifiers to ensure accurate reimbursement and compliance with payer requirements. Below is a list of modifiers that could be used with CPT code 21085, along with the reasons for their use:
1. Modifier 22 - Increased Procedural Services
- Use this modifier if the procedure required significantly more work than typically required. This could be due to the complexity of the patient's condition or other complicating factors.
2. Modifier 52 - Reduced Services
- Apply this modifier if the procedure was partially reduced or eliminated at the physician's discretion. This indicates that the service provided was less than what is typically required for CPT code 21085.
3. Modifier 53 - Discontinued Procedure
- Use this modifier if the procedure was started but discontinued due to extenuating circumstances or those that threaten the well-being of the patient.
4. Modifier 59 - Distinct Procedural Service
- This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. It is particularly useful when billing for multiple procedures that are not typically reported together.
5. Modifier 76 - Repeat Procedure by Same Physician
- Use this modifier if the same physician needs to repeat the procedure on the same day. This indicates that the repeat procedure was necessary and performed by the same provider.
6. Modifier 77 - Repeat Procedure by Another Physician
- Apply this modifier if the procedure needs to be repeated on the same day by a different physician. This helps to clarify that the repeat procedure was necessary and performed by another provider.
7. Modifier 78 - Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period
- Use this modifier if the patient needs to return to the operating room for a related procedure during the postoperative period of the initial surgery.
8. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period
- Apply this modifier if an unrelated procedure or service is performed by the same physician during the postoperative period of the initial procedure.
9. Modifier 80 - Assistant Surgeon
- Use this modifier if an assistant surgeon was required to help perform the procedure. This indicates that another surgeon assisted in the procedure.
10. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- Apply this modifier if an assistant surgeon was necessary because a qualified resident surgeon was not available.
11. Modifier 99 - Multiple Modifiers
- Use this modifier when multiple modifiers are necessary to describe the service provided. This indicates that more than one modifier is applicable to the procedure.
By appropriately applying these modifiers, healthcare providers can ensure that their claims for CPT code 21085 are accurately represented and reimbursed.
Medicare does provide reimbursement for CPT code 21085, which pertains to the preparation of a face/oral prosthesis. However, the reimbursement amount can vary based on several factors, including geographic location, the specific Medicare Administrative Contractor (MAC) overseeing the claim, and whether the service is performed in a facility or non-facility setting.
As of the most recent data, the national average reimbursement rate for CPT code 21085 is approximately $1,200. It is important to verify the exact reimbursement rate with your local MAC and consider any updates to the Medicare Physician Fee Schedule (MPFS) that may affect the amount. Additionally, ensure that all necessary documentation and medical necessity criteria are met to facilitate smooth reimbursement.
Discover how MD Clarity's RevFind software can meticulously analyze your contracts and pinpoint underpayments down to the CPT code level, including specific codes like 21085 for preparing face/oral prostheses. Schedule a demo today to see how RevFind can help you identify and recover lost revenue from individual payers.
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